Provider Demographics
NPI:1740425677
Name:WONG, AMY (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:LAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1404 S SAN GABRIEL BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3603
Mailing Address - Country:US
Mailing Address - Phone:626-863-8578
Mailing Address - Fax:
Practice Address - Street 1:1404 S SAN GABRIEL BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3603
Practice Address - Country:US
Practice Address - Phone:626-863-8578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56140122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist